Impact of non-health policies on infant mortality through the social determinants pathway.

Editorials 778 Infant mortality is an indicator of population health and a measure of global health inequalities. 1 Despite advances in medical sciences and acknowledgement of the role of hygiene and sanitation, survival of infants continues to be a challenge worldwide. Evidence suggests that the survival of infants after the age of one month is mainly influenced by the external environment in which the infant lives, 2 hence, non-health policies targeting the socioeconomic environment are as important as health policies for post-neonatal mortality. 3 Studies both in India and globally suggest that poverty and household income are important upstream determinants of infant mortality. Act targets unemployment and under-employment, and therefore poverty, by providing " at least 100 days of guaranteed paid employment every year to households whose adult members volunteer to do unskilled manual work ". 6 Improved income triggers a cascade of structural and behavioural factors such as better housing and living conditions, food security, access to clean water and proper sanitation, access to health care, infant care and feeding practices that influence the proximal risk factors of infant mortality – malnutrition, diarrhoea and acute respiratory infections. Thus, while the employment programme addresses the central issues of rural poverty , it is likely to transcend its intended goals to improve infant survival. A review of wage-for-employment programmes in 13 countries in Africa and three countries in Asia (Bangla-desh, China and India) demonstrates their positive impact on household income and food security. 7 However, these studies do not demonstrate the impact of such programmes on actual food consumption and nutrition of the target population, or the consequences on child health. Some studies have analysed the impact of employment programmes on infant-feeding practices 8 and child nutrition, 9 but none has demonstrated the composite pathways through which employment may influence child survival. Studies in 19th-century England show higher infant mortality in households with a working mother, which they attribute to the lack of mother's time for infant care, inadequate care, early introduction of artificial feeding and poor living conditions. 10 The Maternal and Infant Nutrition Intervention study in Matlab, in rural Bangladesh, showed that improved household food security is associated with inadequate feeding practices in infants aged less than six months. 8 The authors explain this as an adverse effect of improved household food security, because increased availability of cow's milk, fruit and fruit juices resulted in early weaning of infants. …